[Hiring] Utilization Management Coordinator I @PacificSource Health Plans

Role Description

The Utilization Management (UM) Coordinator I is fundamental to the utilization management team and receives, researches, and coordinates initial and follow-up action related to clinical documentation and requests from a variety of sources. Adheres to rigorous regulatory requirements, builds team collaboration, contributes to team improvements, and creates enhanced member and provider partner relationships.

• Essential Responsibilities:
• Adhere to dependability, member and provider focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all functions.
• Follow stringent guidelines to ensure all work meets PacificSource corporate standards for accuracy and compliance with federal, state, and national accreditation regulations.
• UM Process:
• Coordinate, create, and document UM cases in the electronic record by validating preauthorization requirements, utilizing a basic understanding of ICD, CPT and HCPCS codes, and including plan types, member benefits, eligibility, limitations, exclusions, and claims history.
• Assess accuracy of daily inpatient information from external systems and inpatient facilities, compile inpatient data, create inpatient events including diagnosis codes, and triage for review by UM and CM clinical staff.
• Collaborate with clinical staff by synchronizing information for utilization management, care management, prior authorization, inpatient stay, and retroactive claim reviews.
• Integrate medical records as required and document status of internal or external reviews in the medical record.
• Identify and promptly initiate corrective steps to resolve workflow issues.
• Administratively authorize services as directed by UM Leadership.
• Effectively manage an active telephonic queue by delivering excellent customer service to incoming callers and documenting HIPAA compliance.
• Provide information on prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, claims review, and possess an understanding of when to forward members and providers to Appeals and Grievances.
• Manage difficult calls and escalate or triage calls to more experienced staff as necessary.
• Work between multiple systems, utilizing critical thinking and problem-solving skills while successfully keeping the member at the center.
• Identify and keep readily accessible all up-to-date reference documents, policies and procedures needed to be successful.
• People:
• Attend and contribute to cross-functional member-focused meetings, educate team members on UM functions, and assist members in getting the right care at the right time.
• Utilize knowledge, understanding and critical thinking to research difficult cases related to UM processes and requirements from members, providers, employer groups, agents, member representatives and internal customers.
• Serve as a liaison between members and providers regarding benefit utilization and requirements.
• Provide education and facilitate the member and provider understanding and experience of utilization processes, including benefit structure, contract parameters, and of the information necessary to effectively complete a prior authorization or inpatient stay.
• Supporting Responsibilities:
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Qualifications

• Minimum of two years of experience in health insurance industry or medical setting required.
• One year experience working with CPT/HCPCS/ICD coding preferred.
• High school diploma or equivalent required; associate degree, medical assistant certification, licensed professional nurse or certified professional coding certification preferred.
• Demonstrated basic knowledge and understanding of medical terminology, procedures, anatomy, diagnoses, care modalities, treatment plans, and medical coding.
• Basic understanding of insurance, and standard medical billing practices preferred.
• Proficient computer skills, and strong written and verbal communication skills.
• Strong organizational skills and experience with Microsoft Office programs, medical, and claims management software.
• The ability to work independently at times with minimal supervision.

Requirements

• Accountability
• Collaboration
• Communication (written/verbal)
• Flexibility
• Listening (active)
• Organizational skills/Planning and Organization
• Problem Solving
• Teamwork

Benefits

• Base Range: $35,542.81 - $56,868.50
• Compensation Disclaimer: The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage.

Company Description

• We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.